Submit an Order Patient DemographicsName(Required) First Last Gender(Required)MFAddress(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)Email Date of Birth(Required) Primary Insurance(Required) Member ID(Required) Group #(Required) Please attach a copy of the patient demographics, front and back of insurance card, complete medication list, clinical notes and date of routine EEG. Drop files here or Select files Max. file size: 256 MB. Clinical HistoryMedically Necessary Diagnosis Codes(Required) F44.5 Conversion disorder w/seizures F48.8 Nonpsychotic mental disorders F51.8 Sleep disorders G40.001-G40.919 Seizures G47.00, G47.30, G47.9 Sleep disorders I67.81-I67.85, I67.89 Cerebrovascular diseases R00.0 Tachycardia R06.81 Apnea R25.1 Tremors R25.2 Cramp & spasm R25.3 Fasciculation (Involuntary contractions) R25.8 Abnormal involuntary movements R40.4 Transient alteration of awareness R41.0 Disorientation R41.3 Memory Loss R41.82 Altered mental status R45.1 Restless & Agitation F48.4 Nonpsychotic mental disorders F51.8 Sleep disorders R55 Syncope R56.1 Post traumatic seizures R56.9 Convulsions R94.01 Abnormal EEG S06.2X0A-S06.2X9S Traumatic brain injury Other ICD(s) Medications Order 72-HR Ambulatory EEG with video This order is related to a Letter of Protection/Personal Injury case Previous (if applicable, check all that apply) REEG* AEEG* EMU* Results Normal Abnormal Slowing If no previous REEG is listed above OR one is listed and the results are not provided, I understand a Routine EEG will be performed prior to the 72-HR AEEG and, under those circumstances, I am specifically ordering the Routine EEG to be performed prior to the Ambulatory EEG. *Please provide results for previous test(s).Ordering Healthcare ProviderHealthcare Provider Name(Required) Healthcare Provider Statement: I certify that I am referring the above-named patient for electroencephalographic (EEG) monitoring (routine EEG, 72-HR ambulatory EEG with video) as listed above, and to the best of my knowledge this test is medically necessary in order to diagnose the patient. I understand that the diagnostic testing provided will not itself provide a diagnosis nor will it recommend a therapeutic treatment for this patient. I agreeHealthcare Provider Statement: I certify that I am referring the above-named patient for electroencephalographic (EEG) monitoring (routine EEG, 72-HR ambulatory EEG with video) as listed above, and to the best of my knowledge this test is medically necessary in order to diagnose the patient. I understand that the diagnostic testing provided will not itself provide a diagnosis nor will it recommend a therapeutic treatment for this patient.Healthcare Provider Signature
